Dissection of an Ulnar Nerve Previously Transposed and Wrapped with Human Amniotic Membrane: A Report of 3 Cases.

CASES: We present 3 patients who underwent ulnar nerve transposition and wrapping of the nerve with human amniotic membrane (HAM). All 3 patients subsequently required a reoperation for the original pathologic condition (not for ulnar nerve symptoms), necessitating the exploration and dissection of the transposed ulnar nerve. We demonstrate the lack of scar formation and ease of separation between nerve and surrounding tissue, as well as histology in one case taken from the perineural tissues (previous amniotic membrane), demonstrating no inflammatory cells or absence of scar tissue formation. CONCLUSION: Exploration and dissection of a previously transposed ulnar nerve can be facilitated by wrapping the nerve with HAM to prevent scarring and perineural fibrosis.

Acute ulnar nerve compressive neuropathy at the elbow caused by an accompanying aberrant vessel: A case report

Cubital tunnel syndrome caused by a vessel anomaly is extremely rare. In our case, a patient complained of acute ulnar nerve neuropathy immediately following an operative mass excision at the contralateral elbow. There were no pathologic findings other than twisting of the accompanying vessel around the ulnar nerve. Symptoms were completely relieved following abnormal vessel ligation and ulnar nerve transposition. Hence, we conclude that aberrant vessel paths can cause acute ulnar nerve neuropathy around the elbow

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Prevalence and Clinical Manifestations of the Anconeus Epitrochlearis and Cubital Tunnel Syndrome.

Background: The true prevalence of the anconeus epitrochlearis (AE) and the natural history of cubital tunnel syndrome associated with this anomalous muscle are unknown. The purpose of this study was to evaluate the prevalence of AE and to characterize the preoperative and postoperative features of cubital tunnel syndrome caused by compression from an AE. Methods: All elbow magnetic resonance imaging (MRI) scans and all patients undergoing cubital tunnel surgery during a 20-year period were identified and retrospectively reviewed for the presence of an AE. All patients with an AE identified intra-operatively were matched to patients with no AE identified at surgery based on age, sex, concomitant procedures, and year of surgery. Preoperative and postoperative physical exam findings, electrodiagnostic study results, time to improvement, and reoperations were compared between the groups. Results: A total of 199 patients had an elbow MRI, and 27 (13.6%) patients were noted to have an AE present. Average time to improvement after surgical release was 23.0 days for patients with an AE and 33.2 days for patients with no AE. Twenty-seven patients with an AE noted improvement at the first postoperative visit (68%) compared to 15 patients without an AE (33%). No patients with an AE underwent reoperation for recurrent symptoms (0%) compared with four patients (10%) without an AE. Conclusions: The prevalence of AE in our study is 13.6%. These patients experience quicker and more reliable symptom improvement after surgical release than those without the anomalous muscle.

Outcomes of revision neurolysis of the ulnar nerve and ulnar groove plasty for persistent and recurrent cubital tunnel syndrome-A retrospective study of 21 cases.

BACKGROUND: Patients undergoing revision surgical treatment of the ulnar nerve at the elbow for cubital tunnel syndrome (CuTS) will have worse results compared to patients successfully treated with primary surgery. OBJECTIVE: The purpose of this study is to evaluated clinical outcomes of revision neurolysis and ulnar groove plasty for recurrent and persistent cubital tunnel syndrome after failed surgical treatment. METHODS: This retrospective investigation included patients presented with recurrent and persistent CuTS who were treated surgically with combination of revision neurolysis and ulnar groove plasty at a single institution from May 2006 to Oct 2016 with postoperative follow-up more than 24 months. Demographic data of all patients including age, sex, months to revision surgery, presenting symptoms after index surgery, previous surgical procedure and intraoperative findings were all recorded and pre-operative and post-operative data were compared. McGowen grading was used to evaluated functional impairment before and after revision surgery. RESULTS: There were 28 patients were identified with recurrent and persistent CuTS after primary surgery and 21 patients (75%) were completed in this study with an average age was 56 years, mean duration of symptoms was 17.24 months, and mean postoperative follow-up was 35.38 months. 17 patients had McGowan stage III and 4 had stage II preoperatively. The most common cause of recurrent and persistent CuTS was perineural fibrosis with or without kink which accounts for 86.36% according to intraoperative findings. McGowan grading improved after revision neurolysis and ulnar groove plasty is 80.95%. Improvement of Visual Analogue Scale (VAS) and 2-point discrimination test were 81.25% and 85.71%, respectively. Patients satisfaction after revision neurolysis and ulnar groove plasty was 95.24%. CONCLUSION: The favorable results of this study demonstrated that revision neurolysis and ulnar groove plasty as the treatment of choice for recurrent or persistent cubital tunnel syndrome.

The 7 Structures Distal to the Elbow That Are Critical to Successful Anterior Transposition of the Ulnar Nerve.

Background: Ulnar nerve transposition (UNT) surgery is performed for the treatment of cubital tunnel syndrome. Improperly performed UNT can create iatrogenic pain and neuropathy. The aim of this study is to identify anatomical structures distal to the medial epicondyle that should be recognized by all surgeons performing UNT to prevent postoperative neuropathy. Methods: Ten cadaveric specimens were dissected with attention to the ulnar nerve. Intramuscular UNT surgery was simulated in each. Distal to the medial epicondyle, any anatomical structure prohibiting transposition of the ulnar nerve to a straight-line course across the flexor-pronator mass was noted and its distance from the medial epicondyle was measured. Results: Seven structures were found distal to the medial epicondyle whose recognition is critical to ensuring a successful anterior transposition of the ulnar nerve: (1) Branches of the medial antebrachial cutaneous (MABC) nerve; (2) Osborne's fascia; (3) branches from the ulnar nerve to the flexor carpi ulnaris (FCU); (4) crossing vascular branches from the ulnar artery to the FCU; (5) the distal medial intermuscular septum between the FCU and flexor digitorum superficialis (FDS); (6) the combined muscular origins of the flexor-pronator muscles; and (7) the investing fascia of the FDS. Measurements are given for each structure. Conclusions: Poor outcomes and unnecessary revision surgeries for cubital tunnel syndrome can be avoided with intraoperative attention to 7 structures distal to the medial epicondyle. Surgeons should expect to dissect up to 12 cm distal to the medial epicondyle to adequately address these and prevent kinking of the nerve in transposition.

An anatomical study of so-called fibrous bands around the ulnar nerve distal to the cubital tunnel.

BACKGROUND: Fibrous bands (FB) are structures that cross the ulnar nerve (UN), distal to the cubital tunnel (CT). In surgical decompression of the UN in the elbow region, by endoscopy, these FB significantly impact UN visibility. The aim of the current study was to characterize the anatomical characteristics of these FB distal to the CT. METHODOLOGY: Eighteen formalinized upper limbs were dissected, nine right and nine left, within the Department of Anatomy of the Federal University of the State of Rio de Janeiro (UNIRIO). The dissections were performed with micro techniques, under a magnifying glass and a microscope. Classical UN exposure was established in the elbow region. RESULTS: Of the 18 upper limbs studied, 50% lacked any FB. When present, both the number and location of the FB varied, as near to the cubital tunnel as 3 cm past the UN's entrance into the tunnel, and as far away as almost 11 cm distal to it. Overall, there were no FB on either the left or right side in three cadavers (33.3%), FB on both the left and right side in three, and FB only on the left in three, meaning that FB were twice as common in left limbs (n = 6) as on the right (n = 3). CONCLUSIONS: Our study identified FB in 50% of the dissected limbs, all within 3-11 cm of the CT, though their number and location varied. Further studies are necessary to describe FB variations associated with compressive neuropathies of the UN distal to the CT.

Attrition rupture of ulnar nerve in a patient with rheumatoid elbow arthritis: A case report.

RATIONALE: Cubital tunnel syndrome has been recognized as a common pathology in rheumatoid arthritis (RA) of the elbow. We encountered a patient with RA of the elbow showing attrition rupture of the ulnar nerve. This pathology is extremely rare, and we discussed preventive measures for similar cases in the future based on our case. PATIENT CONCERNS: A 53-year-old woman, received drug treatment for RA since 30 years earlier, had numbness in the left ulnar nerve territory, dorsal interossei muscle atrophy, and resulting claw hand. DIAGNOSES: Plain x-ray examination showed bone destruction of the left elbow joint and marked osteophyte formation in the medial joint space. In nerve conduction velocity (NCV) tests, the Motor NCV was immeasurable in the ulnar nerve territory. Based on these findings, a diagnosis of left cubital tunnel syndrome was made, and anterior transposition of the ulnar nerve was planned. INTERVENTIONS: When the ulnar nerve dissection was advanced, about 80% portion of the ulnar nerve was ruptured. After the ends of the divided nerve were freshened, end-to-end anastomosis was possible by anterior transposition of the ulnar nerve. OUTCOMES: Two years after the operation, numbness and muscle atrophy also remained. There were no changes in the level of daily activities after the operation. However, motor NCV, showed improvement (22.8 m/s) after the operation. LESSONS: In patients with RA showing ulnar neuropathy symptoms, marked osteophyte formation in the medial joint space or valgus deformity may indicate attrition nerve rupture. In the future, when such patients with RA are examined, active nerve exposure and dissection should be considered in terms of ulnar nerve protection.

Cross-sectional area of the ulnar nerve after decompression at the cubital tunnel.

UNLABELLED: A total of 48 patients undergoing surgical decompression of the ulnar nerve at the cubital tunnel between February 2010 and May 2013 were retrospectively studied to determine changes in the cross-sectional area of the nerve by the technique of neurosonography. The mean follow-up was 46 months. Post-operative follow-up examination of the cross-sectional area of the ulnar nerve showed a slight reduction in the mean value from 13.8 mm(2) (pre-operative) to 12.9 mm(2) (post-operative). Of the 48 patients, 36 showed a reduction in the cross-sectional area. No correlation was detected between the clinical and sonographic outcomes. Ultrasound seems to be of limited value in the post-operative assessment of patients with entrapment neuropathy of the ulnar nerve. LEVEL OF EVIDENCE: IV.

Unusual presentation of multiple nerve entrapment: a case report.

Cubital tunnel syndrome is the most common form of ulnar nerve entrapment and the second most common entrapment neuropathy of the upper extremity after carpal tunnel syndrome. However, bilateral compressive ulnar neuropathy is a rare condition. Electro diagnostic studies are a valid and reliable means of confirming the diagnosis.

The anatomy of ulnar nerve branches in anterior transposition.

Cubital tunnel syndrome is the second most common nerve entrapment neuropathy. When non-operative treatments fail, surgical intervention is indicated. Although there remains no consensus between simple decompression and anterior transposition, there is a growing recognition of improved clinical outcomes in the latter. Few details of ulnar nerve branches around the elbow are available however and their sacrifice may be necessary to facilitate anterior transposition. Therefore, ten cadaveric upper extremities were dissected to delineate the course and branching pattern of the ulnar nerve around the elbow joint; anterior transposition was also performed in the cadaveric specimens. Digital photographs of the dissection study were analyzed using the Image J package. Results show that distal ulnar nerve branches are distributed more laterally towards the olecranon and may potentially restrict transposition more than has been recognized; proximal branches may also overlap incision lines of such transposition procedures.

Operative decisions for endoscopic treatment of cubital tunnel syndrome.

The authors review the relevant anatomy and provide technical tips for endoscopic decompression of the cubital tunnel. Cubital tunnel syndrome is the second most common nerve compression syndrome in the upper extremity. Until recently, surgeons focused on open decompression combined with submuscular or subcutaneous transposition of the nerve. Decompression was usually limited to the region of the medial epicondyle, and related morbidity was relatively high. Endoscopic decompression is a promising technique because the dissection range can be extended and the scar length can be reduced. The authors review the relevant anatomy for the endoscopic approach and give some recommendations concerning the details of the surgical technique.

Cubital tunnel syndrome caused by amyloid elbow arthropathy in long-term hemodialysis patients: report of 4 cases.

Carpal tunnel syndrome occurs frequently in long-term hemodialysis patients. However, the literature contains few detailed reports of other nerve entrapment syndromes of the upper extremity in these patients. We encountered 4 cases in which cubital tunnel syndrome occurred in long-term hemodialysis patients. In all cases, a hypertrophic synovial mass projecting from the humeroulnar joint compressed the ulnar nerve, and Congo red staining revealed that the mass contained amyloid deposition. Synovial proliferation resulting from amyloid arthropathy of the elbow joint appears to be the primary cause of this disease.

Cubital tunnel syndrome - a review and management guidelines.

Cubital tunnel syndrome (CuTS) is the second most common peripheral nerve compression syndrome. In German-speaking countries, cubital tunnel syndrome is often referred to as sulcus ulnaris syndrome (retrocondylar groove syndrome). This term is anatomically incorrect, since the site of compression comprises not only the retrocondylar groove but the cubital tunnel, which consists of 3 parts: the retrocondylar groove, partially covered by the cubital tunnel retinaculum (lig. arcuatum or Osborne ligament), the humeroulnar arcade, and the deep flexor/pronator aponeurosis. According to Sunderland , cubital tunnel syndrome can be differentiated into a primary form (including anterior subluxation of the ulnar nerve and compression secondary to the presence of an anconeus epitrochlearis muscle) and a secondary form caused by deformation or other processes of the elbow joint. The clinical diagnosis is usually confirmed by nerve conduction studies. Recently, the use of ultrasound and MRI have become useful diagnostic tools by showing morphological changes in the nerve within the cubital tunnel. A differential diagnosis is essential in atypical cases, and should include such conditions as C8 radiculopathy, Pancoast tumor, and pressure palsy. Conservative treatment (avoiding exposure to external noxes and applying of night splints) may be considered in the early stages of cubital tunnel syndrome. When nonoperative treatment fails, or in patients who present with more advanced clinical findings, such as motor weakness, muscle atrophy, or fixed sensory changes, surgical treatment should be recommended. According to actual randomized controlled studies, the treatment of choice in primary cubital tunnel syndrome is simple in situ decompression, which has to be extended at least 5-6 cm distal to the medial epicondyle and can be performed by an open or endoscopic technique, both under local anesthesia. Simple decompression is also the therapy of choice in uncomplicated ulnar luxation and in most post-traumatic cases and other secondary forms. When the luxation is painful, or when the ulnar nerve actually "snaps" back and forth over the medial epicondyle of the humerus, subcutaneous anterior transposition may be performed. In cases of severe bone or tissue changes of the elbow (especially with cubitus valgus), the anterior transposition of the ulnar nerve may again be indicated. In cases of scarring, submuscular transposition may be preferred as it provides a healthy vascular bed for the nerve as well as soft tissue protection. Risks resulting from transposition include compromise in blood flow to the nerve as well as kinking of the nerve caused by insufficient proximal or distal mobilization. In these cases, revision surgery is necessary. Epicondylectomy is not common, at least in Germany. Recurrence of compression on the ulnar nerve at the elbow may occur. This review is based on the German Guideline "Diagnose und Therapie des Kubitaltunnelsyndroms" ( www.leitlinien.net ).

Operative illustrations of the Osborne's ligament.

The cubital tunnel syndrome is widely considered as the second most frequent compression neuropathy in the upper extremities although the existence of a compressive cause has not been determined conclusively. As far as we know, operational photography of compression of the ulnar nerve at the elbow is almost never found in the literature. In this paper, operational and pathological photographs of the Osborne's ligament as a cause of ulnar entrapment neuropathy at the elbow are presented. There is still an ambiguity as to whether compressive or tractional etiology or both of these factors may occur progressively to be a factor in the development of neuropathy. This report may be considered as concrete evidence for the compressive etiology for ulnar neuropathies.

A tailored approach to the surgical treatment of cubital tunnel syndrome.

Multiple studies have compared the outcome of surgery for cubital tunnel syndrome (CUTS), yet there remains no clear guidelines for treatment. We describe an approach to CUTS that includes tailoring the procedure to the pathology found at surgery. Patients treated surgically were retrospectively reviewed. Following in situ neurolysis, nerve stability within the cubital tunnel was assessed, and the nerve was left in situ, or transposed accordingly. We evaluated demographic information, presenting features, intraoperative and postoperative findings. Statistics included paired t test and logistic regression analysis. A total of 63 patients (standard deviation = 10.3 years) were reviewed. Fourteen nerves were transposed (22.5%). Postoperatively, sensation (71%), static 2-point discrimination, and motor strength improved. Grip strength compared with the uninvolved side was 94.8% postoperatively. Overall, 90% of the patients reported improvement in function. Our results compare favorably with other studies. Since CUTS originates from numerous causes, basing the operative plan on intraoperative findings produces excellent results.

High resolution ultrasonography in the diagnosis of ulnar nerve lesions with particular reference to post-traumatic lesions and sites outside the elbow.

OBJECTIVE: Recent studies suggest that high resolution ultrasonography (HRU) is useful in evaluating ulnar neuropathy (UN) at the elbow. These studies do not include UN outside the elbow and lesions related to previous trauma. We investigate diagnostic utility of HRU in UN at any location of traumatic and non-traumatic etiology. METHODS: Patients with clinically suspected and electrophysiologically defined UN at the elbow and outside the elbow were included. Nerve conduction studies (NCS) were compared with HRU. HRU defined UN in terms of change in cross-sectional area. RESULTS: Our retrospective analysis included 46 UN. In 25 cases both NCS and HRU localised neuropathy to the elbow. In 15 where NCS was abnormal but non-localising, HRU localised the lesion in 14, 7 outside the elbow. In three of these, HRU characterised further pathology (synovial osteochondromatosis (n=2), myositis ossificans (n=1). Cross-sectional area of the ulnar nerve at the sulcus significantly correlated with distal NCS parameters. CONCLUSIONS: HRU is of greater use than NCS in the localisation of UN both at the elbow and outside the elbow and in UN related to previous trauma. SIGNIFICANCE: HRU is useful for the localisation of ulnar neuropathy.

Simple endoscopic decompression of cubital tunnel syndrome with the Agee system: anatomic study and first clinical results.

BACKGROUND: Simple decompression in ulnar nerve compression syndromes offers options for endoscopic applications. OBJECTIVE: The authors present their initial experience with the Agee device. PATIENTS AND METHODS: The monoportal endoscopic technique (Agee system) was evaluated on 10 cadaveric arms. Subsequently, 32 arms of 29 patients were operated on between January 2006 and March 2009. All patients presented with typical clinical signs and neurophysiologic studies. Long-term follow-up examinations were obtained in 27 of 32 arms. RESULTS: In the cadaver study, the ulnar nerve was always correctly identified. No nerve damage occurred, and sufficient decompression of the ulnar nerve was always achieved. In the clinical series, no intraoperative complications were observed. A change to open technique was not required, and no worsening of the cubital tunnel syndrome occurred. Two wound infections required surgical wound cleaning. Wound hematomas treated conservatively were found in 5 cases. On long-term follow-up, an improvement in the McGowan- Classification was achieved in 22 of 27 cases. One patient was operated on by open surgery after endoscopic surgery. CONCLUSION: The endoscopic technique for ulnar nerve entrapment syndrome using an Agee device appears to be safe and efficient. The results are comparable to those achieved with simple open decompression. A randomized prospective study should be performed to further evaluate the value of new technique in ulnar nerve entrapment syndrome.

Diffusion-weighted magnetic resonance imaging of the ulnar nerve in cubital tunnel syndrome.

Diffusion-weighted images based on magnetic resonance reveal the microstructure of tissues by monitoring the random movement of water molecules. In this study, we investigated whether this new technique could visualize pathologic lesions on ulnar nerve in cubital tunnel. Six elbows in six healthy males without any symptoms and eleven elbows in ten patients with cubital tunnel syndrome underwent on diffusion-weighted MRI. No signal from the ulnar nerve was detected in normal subjects. Diffusion-weighted MRI revealed positive signals from the ulnar nerve in all of the eleven elbows with cubital tunnel syndrome. In contrast, conventional T2W-MRI revealed high signal intensity in eight elbows and low signal intensity in three elbows. Three elbows with low signal MRI showed normal nerve conduction velocity of the ulnar nerve. Diffusion-weighted MRI appears to be an attractive technique for diagnosis of cubital tunnel syndrome in its early stages which show normal electrophysiological and conventional MRI studies.